Utilizing the Biopsychosocial Model in Concussion Treatment: Post-Traumatic Headache and beyond

Metacognitive Therapy for People Experiencing Persistent Post-Concussion Symptoms Following Mild Traumatic Brain Injury: A Preliminary Multiple Case-Series Study

After mild traumatic brain injury (mTBI), a subgroup of individuals experience persistent post-concussion symptoms (PPCS) that include headaches, cognitive difficulties, and fatigue. The aim of this preliminary study was to investigate possible effects associated with metacognitive therapy (MCT) on PPCS, maladaptive coping strategies, and positive and negative metacognitive beliefs following mTBI. A pre-post design supplemented with single-case A-B replication series to assess potential MCT mechanisms was used. Of the nine participants who received MCT, all experienced a decrease in PPCS, which constituted a reliable improvement for eight participants. For eight participants (we could calculate effect sizes for eight out of nine participants), moderate to very large decreases in maladaptive coping styles and positive and negative metacognitive beliefs were observed. However, based on visual analyses, participants 6, 8, and 9 show a downward baseline trend regarding MCT mechanisms that may have persisted into the intervention phase. No adverse events were reported. In conclusion, MCT was associated with improvements in PPCS and unhelpful psychological mechanisms, but caution is required in interpreting this association. Future research using formal single-case replication on symptom measures and randomized controlled trials appears to be justified.

Feasibility of superimposed supine cycling and lower body negative pressure as an effective means of prolonging exercise tolerance in individuals experiencing persisting post-concussive symptoms: Preliminary results

To examine the feasibility, utility and safety of superimposed lower body negative pressure (LBNP) and tilt during supine cycling in individuals suffering from persisting post-concussive symptoms (PPCS). Eleven individuals aged 17-31 (6 females/5 males) participated in two randomized separate visits, 1 week apart. A ramp-incremental test was performed during both visits until volitional failure. Visits included no pressure (control) or LBNP at -40 Torr (experimental) with head-up tilt at 15 degrees (females) or 30 degrees (males). Transcranial Doppler ultrasound was utilized to quantify middle cerebral artery velocity (MCAv), while symptom reports were filled out before and 0, 10, and 60 min post-exertion. Ratings of exertion and overall condition followed similar trends for participants across both tests. The relative increase in MCAv was blunted during the experimental condition (8%) compared to control (24%), while a greater heart rate (17 beats/min) was achieved during the LBNP condition (P = 0.047). Symptom severity at the 0 and 10 min post-exertion time points displayed negligible-to-small effect sizes between conditions (Wilcoxon's r < 0.11). Symptom reporting was lower at the 60 min post-exertion time point with these displaying a moderate effect size (Wilcoxon's r = 0.31). The combination of LBNP and tilt during supine cycling did not change the participants' subjective interpretation of the exertional test but attenuated the hyperpnia-induced vasodilatory MCAv response, while also enabling participants to achieve a higher heart rate during exercise and reduced symptoms 1 h later. As this protocol is safe and feasible, further research is warranted in this area for developing PPCS treatment options. HIGHLIGHTS: What is the central question of this study? What are the feasibility, safety and utility of combining head-up tilt with lower body negative pressure during supine cycling for blunting the increase in cerebral blood velocity seen during moderate-intensity exercise in individuals experiencing persisting post-concussion symptoms? What is the main finding and its importance? Although no differences were found in symptoms between conditions within the first 10 min following exertion, symptom severity scores showed a clinically meaningful reduction 60 min following the experimental condition compared to the non-experimental control condition.

Sensor-Assisted Analysis of Autonomic and Cerebrovascular Dysregulation following Concussion in an Individual with a History of Ten Concussions: A Case Study

INTRODUCTION

Concussion is known to cause transient autonomic and cerebrovascular dysregulation that generally recovers; however, few studies have focused on individuals with an extensive concussion history.

METHOD

The case was a 26-year-old male with a history of 10 concussions, diagnosed for bipolar type II disorder, mild attention-deficit hyperactivity disorder, and a history of migraines/headaches. The case was medicated with Valproic Acid and Escitalopram. Sensor-based baseline data were collected within six months of his injury and on days 1-5, 10, and 14 post-injury. Symptom reporting, heart rate variability (HRV), neurovascular coupling (NVC), and dynamic cerebral autoregulation (dCA) assessments were completed using numerous biomedical devices (i.e., transcranial Doppler ultrasound, 3-lead electrocardiography, finger photoplethysmography).

RESULTS

Total symptom and symptom severity scores were higher for the first-week post-injury, with physical and emotional symptoms being the most impacted. The NVC response showed lowered activation in the first three days post-injury, while autonomic (HRV) and autoregulation (dCA) were impaired across all testing visits occurring in the first 14 days following his concussion.

CONCLUSIONS

Despite symptom resolution, the case demonstrated ongoing autonomic and autoregulatory dysfunction. Larger samples examining individuals with an extensive history of concussion are warranted to understand the chronic physiological changes that occur following cumulative concussions through biosensing devices.

"Alone in the dark": A qualitative study of treatment experiences among young adults with a recent concussion and anxiety

PURPOSE

Young adults with anxiety are vulnerable to developing persistent symptoms following concussions. In order to develop psychosocial interventions to prevent persistent post-concussion symptoms, we need to understand patients' 1) experiences with treatments offered by health care providers; 2) experiences with attempted concussion management strategies; and 3) needs after their injury.

METHODS

We conducted in-depth interviews with 17 young adults with recent (≤ 10 weeks) concussions who have at least mild anxiety (Generalized Anxiety Disorder Assessment-7 ≥ 5). We used a hybrid deductive-inductive approach to thematic analysis.

RESULTS

Findings provide insight into recommended treatments (e.g., active/avoidant strategies, accommodations, referrals), attempted strategies (e.g., lifestyle changes, pacing, relationships, acceptance-based coping skills), and patient needs (e.g., education, accommodations, referrals for cognitive and emotional skills). Participants frequently expressed that treatment recommendations were confusing and difficult to implement. They initiated non-prescribed strategies that helped promote recovery and expressed a desire for more interdisciplinary treatment and education on concussions.

CONCLUSION

Patients' perceptions of health care provider recommendations after concussions did not fully meet patients' perceived needs. Young adults with concussions and anxiety would benefit from more education, guidance, and psychosocial and rehabilitation services. Addressing these gaps may help align treatments with patients' needs and therefore help optimize their recovery.

Applying the National Institute on Minority Health and Health Disparities Research Framework to Social Determinants of Health in the Context of Sport-Related Concussion: A Clinical Commentary

Sport-related concussion (SRC) is a prevalent injury. Significant disparities in SRC outcomes exist across racial and ethnic groups. These disparities may be attributed to the unequal distribution of political power (or influence) and resource allocation in various communities, shaping individuals' social determinants of health (SDOH). However, the influence of SDOH on SRC outcomes remains understudied. In this clinical commentary, we use the National Institute on Minority Health and Health Disparities Research Framework and describe how its application can help address gaps in our understanding of SDOH and SRC. This framework provides a comprehensive approach to investigating and addressing health disparities by considering SDOH along multiple levels and domains of influence. Using this framework, athletic trainers can identify areas requiring intervention and better understand how SDOH influence SRC outcomes. This understanding can help athletic trainers develop tailored interventions to promote equitable care for patients with SRC.

Outcomes and Management After COVID-19 Critical Illness

TOPIC IMPORTANCE

COVID-19 has caused > 7 million deaths worldwide since its onset in 2019. Although the severity of illness has varied throughout the pandemic, critical illness related to COVID-19 persists. Survivors of COVID-19 critical illness can be left with sequelae of both the SARS-CoV-2 virus and long-term effects of critical illness included within post-intensive care syndrome. Given the complexity and heterogeneity of COVID-19 critical illness, the biopsychosocial-ecological model can aid in evaluation and treatment of survivors, integrating interactions among physical, cognitive, and psychological domains, as well as social systems and environments.

REVIEW FINDINGS

Prolonged illness after COVID-19 critical illness generally can be classified into effects on physical, cognitive, and psychosocial function, with much interaction among the various effects, and includes a wide range of symptoms such as ICU-acquired weakness, prolonged respiratory symptoms, cognitive changes, post-traumatic stress disorder post-traumatic stress disorder, anxiety, and depression. Risk factors for COVID-19 critical illness developing are complex and include preexisting factors, disease course, and specifics of hospitalization in addition to psychological comorbidities and socioenvironmental factors. Recovery trajectories are not well defined, and management requires a comprehensive, interdisciplinary, and individualized approach to care.

SUMMARY

The onset of vaccinations, new therapeutics, and new strains of SARS-CoV-2 virus have decreased COVID-19 mortality; however, the number of survivors of COVID-19 critical illness remains high. A biopsychosocial-ecological approach is recommended to guide care of COVID-19 critical illness survivors.

Longitudinal Associations Between Persistent Post-Concussion Symptoms and Blood Biomarkers of Inflammation and CNS-Injury After Mild Traumatic Brain Injury

The aim of our study was to investigate the biological underpinnings of persistent post-concussion symptoms (PPCS) at 3 months following mild traumatic brain injury (mTBI). Patients (n = 192, age 16-60 years) with mTBI, defined as Glasgow Coma Scale (GCS) score between 13 and 15, loss of consciousness (LOC) <30 min, and post-traumatic amnesia (PTA) <24 h were included. Blood samples were collected at admission (within 72 h), 2 weeks, and 3 months. Concentrations of blood biomarkers associated with central nervous system (CNS) damage (glial fibrillary acidic protein [GFAP], neurofilament light [NFL], and tau) and inflammation (interferon gamma [IFNγ], interleukin [IL]-8, eotaxin, macrophage inflammatory protein-1-beta [MIP]-1β, monocyte chemoattractant protein [MCP]-1, interferon-gamma-inducible protein [IP]-10, IL-17A, IL-9, tumor necrosis factor [TNF], basic fibroblast growth factor [FGF]-basic platelet-derived growth factor [PDGF], and IL-1 receptor antagonist [IL-1ra]) were obtained. Demographic and injury-related factors investigated were age, sex, GCS score, LOC, PTA duration, traumatic intracranial finding on magnetic resonance imaging (MRI; within 72 h), and extracranial injuries. Delta values, that is, time-point differences in biomarker concentrations between 2 weeks minus admission and 3 months minus admission, were also calculated. PPCS was assessed with the British Columbia Post-Concussion Symptom Inventory (BC-PSI). In single variable analyses, longer PTA duration and a higher proportion of intracranial findings on MRI were found in the PPCS group, but no single biomarker differentiated those with PPCS from those without. In multi-variable models, female sex, longer PTA duration, MRI findings, and lower GCS scores were associated with increased risk of PPCS. Inflammation markers, but not GFAP, NFL, or tau, were associated with PPCS. At admission, higher concentrations of IL-8 and IL-9 and lower concentrations of TNF, IL-17a, and MCP-1 were associated with greater likelihood of PPCS; at 2 weeks, higher IL-8 and lower IFNγ were associated with PPCS; at 3 months, higher PDGF was associated with PPCS. Higher delta values of PDGF, IL-17A, and FGF-basic at 2 weeks compared with admission, MCP-1 at 3 months compared with admission, and TNF at 2 weeks and 3 months compared with admission were associated with greater likelihood of PPCS. Higher IL-9 delta values at both time-point comparisons were negatively associated with PPCS. Discriminability of individual CNS-injury and inflammation biomarkers for PPCS was around chance level, whereas the optimal combination of biomarkers yielded areas under the curve (AUCs) between 0.62 and 0.73. We demonstrate a role of biological factors on PPCS, including both positive and negative effects of inflammation biomarkers that differed based on sampling time-point after mTBI. PPCS was associated more with acute inflammatory processes, rather than ongoing inflammation or CNS-injury biomarkers. However, the modest discriminative ability of the models suggests other factors are more important in the development of PPCS.

National Athletic Trainers' Association Bridge Statement: Management of Sport-Related Concussion

OBJECTIVE

To provide athletic trainers and team physicians with updated recommendations to the 2014 National Athletic Trainers' Association (NATA) concussion position statement regarding concussion management, specifically in the areas of education, assessment, prognostic factors, mental health, return to academics, physical activity, rest, treatment, and return to sport.

BACKGROUND

Athletic trainers have benefited from the 2 previous NATA position statements on concussion management, and although the most recent NATA position statement is a decade old, knowledge gains in the medical literature warrant updating several (but not all) recommendations. Furthermore, in various areas of the body of literature, current evidence now exists to address items not adequately addressed in the 2014 statement, necessitating the new recommendations. This document therefore serves as a bridge from the 2014 position statement to the current state of concussion evidence, recommendations from other organizations, and discrepancies between policy and practice.

RECOMMENDATIONS

These recommendations are intended to update the state of the evidence concerning the management of patients with sport-related concussion, specifically in the areas of education; assessment advances; prognostic recovery indicators; mental health considerations; academic considerations; and exercise, activity, and rehabilitation management strategies.

A Common Data Element-Based Adjudication Process for mTBI Clinical Profiles: A Targeted Multidomain Clinical Trial Preliminary Study

INTRODUCTION

The primary purpose of this study was to examine the prevalence and percent agreement of clinician-identified mild traumatic brain injury (mTBI) clinical profiles and cutoff scores for selected Federal Interagency Traumatic Brain Injury Research common data elements (CDEs). A secondary purpose was to investigate the predictive value of established CDE assessments in determining clinical profiles in adults with mTBI.

MATERIALS AND METHODS

Seventy-one (23 males; 48 females) participants (M = 29.00, SD = 7.60, range 18-48 years) within 1-5 months (M = 24.20, SD = 25.30, range 8-154 days) of mTBI completed a clinical interview/exam and a multidomain assessment conducted by a licensed clinician with specialized training in concussion, and this information was used to identify mTBI clinical profile(s). A researcher administered CDE assessments to all participants, and scores exceeding CDE cutoffs were used to identify an mTBI clinical profile. The clinician- and CDE-identified clinical profiles were submitted to a multidisciplinary team for adjudication. The prevalence and percent agreement between clinician- and CDE-identified clinical profiles was documented, and a series of logistic regressions with adjusted odds ratios were performed to identify which CDE assessments best predicted clinician-identified mTBI clinical profiles.

RESULTS

Migraine/headache, vestibular, and anxiety/mood mTBI clinical profiles exhibited the highest prevalence and overall percent agreement among CDE and clinician approaches. Participants exceeding cutoff scores for the Global Severity Index and Headache Impact Test-6 assessments were 3.90 and 8.81 times more likely to have anxiety/mood and migraine/headache profiles, respectively. The Vestibular/Ocular Motor Screening vestibular items and the Pittsburgh Sleep Quality Index total score were predictive of clinician-identified vestibular and sleep profiles, respectively.

CONCLUSIONS

The CDEs from migraine/headache, vestibular, and anxiety/mood domains, and to a lesser extent the sleep modifier, may be clinically useful for identifying patients with these profiles following mTBI. However, CDEs for cognitive and ocular may have more limited clinical value for identifying mTBI profiles.

Influence of Personal and Injury-Related Factors Predicting Deficits in Quality of Life Domains Among Pediatric Athletes: Findings From the Sport Concussion Outcomes in Pediatrics Study

OBJECTIVE

To examine patient and injury factors that may predict quality of life (QoL) and symptom duration after concussion.

DESIGN

Prospective, longitudinal.

SETTINGS

Six children's hospital-based medical centers and 9 secondary school athletic training facilities.

PATIENTS

Pediatric patients (8-18 years) were enrolled as part of the Sport Concussion Outcomes in Pediatrics (SCOPE) study during their initial visit for a diagnosis of sport-related concussion.

INTERVENTIONS

Patients completed a medical history, the Postconcussion Symptom Inventory (PCSI), and Patient-Reported Outcomes Measurement Information System Pediatric Profile-25 (PROMIS-PP).

MAIN OUTCOME MEASURES

Eight predictor variables [age, sex, assessment time, loss of consciousness, amnesia and history of concussion, migraines, or attention-deficit hyperactivity disorder or (ADHD)] were assessed using regression models constructed for each dependent variable.

RESULTS

A total of 244 patients (15.1 ± 2.1 years, 41% female) were enrolled (mean = 5 ± 3 days after concussion; range = 1-14 days). Female sex, later initial assessment, and presence of amnesia were associated with lower QoL scores on several domains, whereas loss of consciousness was associated with higher QoL for fatigue. A history of migraines was associated with lower peer relationship QoL. Patients who subsequently developed persisting symptoms had lower mobility scores and higher anxiety, depressive symptom, fatigue, and pain interference scores.

CONCLUSIONS

Female sex, later clinic presentation, and amnesia were associated with a lower QoL related to mobility, anxiety, depressive symptoms, fatigue, and pain interference. Interestingly, previous concussion and preinjury ADHD diagnosis did not negatively impact postinjury QoL at the initial visit. Future studies should assess the influence of these factors on QoL at later postinjury time points using a concussion-specific outcomes instrument.

Network analysis applied to post-concussion symptoms in two mild traumatic brain injury samples

Objective

A latent disease explanation cannot exclusively explain post-concussion symptoms after mild traumatic brain injury (mTBI). Network analysis offers an alternative form of explanation for relationships between symptoms. The study aimed to apply network analysis to post-concussion symptoms in two different mTBI cohorts; an acute treatment-seeking sample and a sample 10 years post-mTBI.

Method

The treatment-seeking sample (n = 258) were on average 6 weeks post-injury; the 10 year post mTBI sample (n = 193) was derived from a population-based incidence and outcomes study (BIONIC). Network analysis was completed on post-concussion symptoms measured using the Rivermead Post-Concussion Questionnaire.

Results

In the treatment-seeking sample, frustration, blurred vision, and concentration difficulties were central to the network. These symptoms remained central in the 10 year post mTBI sample. A Network Comparison Test revealed evidence of a difference in network structure across the two samples (p = 0.045). However, the only symptoms that showed significant differences in strength centrality across samples were irritability and restlessness.

Conclusion

The current findings suggest that frustration, blurred vision and concentration difficulties may have an influential role in the experience and maintenance of post-concussion symptoms. The impact of these symptoms may remain stable over time. Targeting and prioritising the management of these symptoms may be beneficial for mTBI rehabilitation.

POST-TRAUMATIC PSYCHOLOGICAL INTERVENTION IN COLLEGE ATHLETES

ABSTRACT Introduction: Injuries will always be with an athlete throughout their career. When analyzing the factors that cause athletic injuries, their coaches usually consider environmental and physical training factors, ignoring psychological factors. Objective: Investigate the mental health status of college athletes after serious injuries during competition, discussing the impact of sports injuries on athletes' mental health. Methods: Twelve college athletes were selected as research volunteers. They were divided into two groups by randomization. The control group was followed by traditional psychotherapy while the experimental group received the post-traumatic mental intervention. A comparison was carried out and mainly the general situation of sports injuries and the effect of intervention treatment were analyzed. The impact of psychological intervention methods on athletes' mental health after injuries were also studied using mathematical statistics to analyze the data. Results: There were significant differences in STAI scores in the experimental group before and after the intervention. BFS scores in the experimental group were significantly higher than those in the control group before and after an intervention. There was no significant difference in the indicators in the control group. Conclusion: Post-traumatic psychological intervention positively affects the mental health recovery of college athletes. Level of evidence II; Therapeutic studies - investigation of treatment outcomes.

Tele-Active Rehabilitation for Youth With Concussion: Evidence-Based and Theory-Informed Intervention Development

BACKGROUND

Active rehabilitation involving subsymptom threshold exercise combined with education and support promotes recovery in youth with concussion but is typically delivered in person, which may limit accessibility for families because of a lack of services in their communities or logistical challenges to attending in-person sessions.

OBJECTIVE

This paper describes the evidence-based and theory-informed development of the Tele-Active Rehabilitation (Tele-AR) intervention for pediatric concussion, which was specifically designed for remote service delivery.

METHODS

The intervention was designed by clinician-researchers with experience in pediatric concussion rehabilitation following the Medical Research Council guidance for developing complex interventions. Development involved a critical review of the literature to identify existing evidence, the expansion of the theoretical basis for active rehabilitation, and the modeling of the intervention process and outcomes.

RESULTS

Tele-AR is a 6-week home exercise and education and support program facilitated through weekly videoconferencing appointments with a clinician. Exercise consists of low- to moderate-intensity subsymptom threshold aerobic activity and coordination drills that are individualized to participant needs and interests (prescribed for 3 days per week). Education includes the evidence-supported Concussion & You self-management program, which covers topics related to energy management, nutrition, hydration, sleep hygiene, and return to activity. Elements of self-determination theory are incorporated to support motivation and engagement. We present a logic model describing predicted intervention effects using a biopsychosocial conceptualization of outcomes after concussion.

CONCLUSIONS

The Tele-AR intervention may help to increase access to care that improves recovery and promotes a timely return to activity in youth with concussion. Future research is needed to evaluate the feasibility and efficacy of this approach.

Examining the association between psychosocial functioning and concussion symptom severity in youth

OBJECTIVE

Guidelines recommend examining psychosocial variables as contributors to postconcussive symptoms. However, few studies examined this relation in a clinic-referred sample and fewer accounted for parent perspective, limiting practitioners implementation of this guidance. Therefore, this longitudinal study examined youth and parent-reported psychosocial variables and their association with concussion symptom severity in a clinic-referred sample of youth receiving treatment for concussion.

METHODS

Youth (n = 121; mean age = 15.3 years) with a recent concussion and their parents completed measures assessing youth depression, anxiety, academic stress, quality of life and concussion symptom severity at the initial treatment appointment and again approximately three-months later or at discharge, whichever came first.

RESULTS

Differences were observed in psychosocial functioning across parent and youth report. Youth-reported depression was strongly associated with concussion symptom severity whereas parent-reported depression, academic stress, and quality of life were significantly related to concussion symptom severity. Exploratory findings of the relation between psychosocial variables at initial evaluation and concussion symptom severity at follow-up are offered.

CONCLUSION

Results offer guidance on the underlying psychosocial variables that may be useful to consider when developing interventions for youth recovering from concussion, especially those with a prolonged recovery.

Reason to doubt the ICHD-3 7-day inclusion criterion for mild TBI-related posttraumatic headache: A nested cohort study

Background

Posttraumatic headache is difficult to define and there is debate about the specificity of the 7-day headache onset criterion in the current definition. There is limited evidence available to guide decision making about this criterion.

Method

A nested cohort study of 193 treatment-seeking veterans who met criteria for persistent headache attributed to mild traumatic injury to the head, including some veterans with delayed headache onset up to 90 days post-injury, was undertaken. Survival analysis examined the proportion of participants reporting headache over time and differences in these proportions based on sex, headache phenotype, and mechanism of injury.

Result

127 participants (66%; 95% CI: 59–72%) reported headache onset within 7 days of head injury and 65 (34%) reported headache onset between 8 days and 3 months after head injury. Fourteen percent of participants reported pre-existing migraine before head injury, and there was no difference in the proportion of veterans with pre-existing migraine based on headache onset. Headache onset times were not associated with sex, headache phenotype, or mechanism of injury. There were no significant differences in proportion of veterans with headache onset within 7 days of head injury based on headache phenotype (70% migraine onset within 7 days, 70% tension-type headache within 7 days, 56% cluster headache within 7 days; p ≥ .364). Similar findings were observed for head injury (64% blast, 60% blunt; p = .973). There were no significant differences observed between headache onset groups for psychiatric symptoms (Posttraumatic Stress Disorder Checklist for DSM-5 = 1.3, 95% CI = −27.5, 30.1; Patient Health Questionnaire-9 Item = 3.5, 95% CI = −6.3, 3.7; Generalized Anxiety Disorder Screener = 6.5, 95% CI = −2.7, 15.6).

Conclusions

Although most of the sample reported headache onset within 7 days of head injury, one-third experienced an onset outside of the diagnostic range. Additionally, veterans with headache onset within 7 days of head injury were not meaningfully different from those with later onset based on sex, headache phenotype, or mechanism of head injury. The ICHD-3 diagnostic criteria for 7-day headache onset should be expanded to 3 months.

ClinicalTrials.gov Identifier

NCT02419131